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such subjects also, in cutting the flap upwards, I avoid taking all the fleshy mass in front of the bone, but cut it upwards so as to have about half the thickness of the extensor muscles-a sufficient quantity of flesh and skin for surrounding the end of the bone is thus obtained.

"2. I believe the extent of suppurating surface is nearly the same in rectangular as in the two other modes of amputating, provided the operations are all equally well performed so as to secure a good stump.

"3. I make the lateral incision of the long flap through the integuments only, in order to allow for a little transverse contraction of skin, and thereby to secure the perfect covering of the muscles by skin; otherwise a little bulging out of muscles at the sides might require the skin to be too tightly drawn over the sides of the stump. These remarks apply mainly to amputation of the thigh. My son is very well, and joins me in kindest remembrance, &c.

"H. G. Croly, Esq."

"Believe me, my dear Sir,

Yours most truly,

"THOMAS P. TEALE.

From the foregoing details of the rectangular flap amputation the following practical conclusions may be deduced:—

1. This mode of operating combines the advantages of both the circular and the flap amputation, without the disadvantages of either. The vessels are divided at right angles, and ample covering of muscle is provided for the bone, while the adherent cicatrix is avoided.

2. The mortality is less after amputation by this mode than by other methods according to statistics already published, and the result of the operation performed by myself and others in this country confirms this important fact.

3. Tension is avoided by ample flaps.

4. The plastic process is not interfered with, and the liability to purulent absorption is diminished.

5. The lateral incisions in most cases unite quickly, and the transverse incision allows the discharges to escape freely.

6. There is no need of bandaging or other dressing, but simply to place the stump on a pillow covered with oiled silk.

7. In marking out the lines for this amputation in the thigh, the surgeon must be careful to avoid including the femoral artery in

the long flap, or splitting the vessel where it pierces the adductor magnus muscle.

8. In amputations of the leg there is a danger of wounding the anterior tibial artery at the base of the flap; to avoid this the handle of the scalpel should be used in raising up the vessels from the inter-osseous membrane; and in the operation high up in the leg the surgeon must be careful not to cut the origin of the anterior tibial artery when dissecting the short flap.

ART. XIV.-Reports of Hospital Cases.—On Injuries of the Wrist and Ankle Joints. By WILLIAM MAC CORMAC, M.A., M.D., Q.U.I., F.R.C.S.I.; Surgeon to the Belfast General Hospital; and Vice-President of the Ulster Medical Society.

I.-EXTENSIVE

INJURY OF THE HAND, NECESSITATING THE REMOVAL OF THE WHOLE OF THE CARPUS, AND OF MOST OF THE METACARPUS-RECOVERY WITH A USEFUL LIMB.

II-LACERATED WOUND OF THE BACK OF THE WRIST, INVOLVING THE JOINTS OF THE CARPUS-RECOVERY WITH A USEFUL HAND.

III. LACERATION OF THE BACK OF THE WRIST, INVOLVING THE CARPAL JOINTS, AND ALSO OF THE PALM-RECOVERY WITH A USEFUL HAND.

IV.—COMPOUND DISLOCATION INWARDS OF THE ANKLE JOINT, WITH FRACTURE OF THE INNER MALLEOLUS, AND COMMINUTED FRACTURE OF THE FIBULA-DEATH FROM PYEMIA.

V. COMPOUND DISLOCATION OF THE ANKLE JOINT, WITH COMPLETE DISLOCATION OF THE ASTRAGALUS OUTWARDSEXCISION OF THE BONE-RECOVERY WITH A USEFUL FOOT.

IN the following paper I purpose giving an account of some cases of injury of the wrist and ankle joints. I believe they will be considered interesting since they serve to show how far it is possible, in some instances at least, to preserve a limb and its usefulness after severe injury and under rather unfavourable circumstances.

In an hospital situated in the midst of a large manufacturing population, cases of accident are of necessity frequent, and of these none are more so than injuries of the hand or arm requiring partial

or complete amputation. Of course in such cases the practice of conservative surgery should be carried to the utmost limit that it can be with prudence brought. To none is this of greater moment than to working men and women. Unfortunately the mill-working class, who are most frequently the subject of such injuries, are not usually in the enjoyment of the best health. They are confined many hours in close ill-ventilated rooms by day, and in yet closer and worse ventilated rooms by night, while too often their habitual food is of the most innutritious kind. The consequence is that when they incur injuries by machinery, injuries which in spite of the best directed efforts to guard against them but too frequently happen, the wounds often fail to heal kindly. Frequently a wound will close up and seem to have united by the first intention, yet after the lapse of a day or two the adhesions will break down, and more or less unhealthy inflammation be set up, not seldom accompanied by diffuse suppuration in the neighbourhood of the hurt.

I am able to submit to the readers of this Journal not only the history and treatment of each of the following cases, but also the condition of the patient at a considerable interval after recovery, when the amount of usefulness the limb was likely to attain to might be more fairly estimated.

I thought it desirable yet further to illustrate the results by lithographs copied either from careful drawings of the parts, or from photographs. The plates have been faithfully and beautifully executed.

Without further preface, then, I shall proceed to furnish the particulars of the first case.

I. Mary Jane Waterson, an interesting child of ten years of age, was admitted to hospital under my care, May 21st, 1866. She was employed in one of the mills on "full time," contrary to the Act of Parliament. Whilst she was engaged on the morning of the 21st cleaning a spinning frame, her left hand was caught between the cog-wheels at the end of the machine. Accidents caused by these wheels are very frequent, and as may be imagined any portion of the hand which passes between them must be irretrievably injured. It often looks, in fact, somewhat as if it had been teased out like a piece of oakum.

On examining the child's hand, I found three-fifths of it in a shocking condition. The middle, third, and little fingers had been entangled, as well as the corresponding metacarpal bones. The

soft parts covering them were cut up into shreds, while the bones. themselves were comminuted. The forefinger as far as the middle of the second phalanx, was also quite chopped up, the term really best fitted to express the character of the injury. In short, the entire inner portion of the hand, up to the wrist joint, was hanging semi-detached from the stump of the forefinger and the thumb which last, fortunately, was uninjured.

At first sight, it appeared as if amputation, at or above the wrist, were the only thing practicable, the more so, as the dragging and stretching of the soft parts which so frequently accompany accidents such as this, inflict injury which does not at first meet the eye, and prove the source of sloughing and secondary hemorrhage with all their attendant ills. This is more especially the case when amputation is performed too near the seat of injury.

I determined, however, if it were possible, to try to save at least a portion of the mutilated hand.

The little patient having been put under the influence of chloroform, an incision was made through the sound structures left, as near as practicable to the lacerated margins, commencing at the base of the forefinger, and extending on the palmar and dorsal aspects of the hand as high as the wrist. Only those parts were removed which, had they been retained, would inevitably have perished. The carpus, then, remained quite exposed, and there were no soft tissues available wherewith to form even a partial covering. Considering the free inter-communication of the carpal joints, the probability of severe inflammation being set up in them, possibly followed by death of the greater portion of the carpus, and at the best subsequent anchylosis of the wrist joint, should amputation not prove necessary, I thought it better to excise it at once. Accordingly I removed the entire carpus, which is a somewhat remarkable feature in this case. The ends of the metacarpal bones of the thumb and index finger were then placed in contact with the end of the radius, which, with the ulna, had not been interfered with. But it was not until I had snipped off with bone forceps the projecting extremity of the metacarpal bone of the index finger, that I could draw the edges of the skin together. The ulnar artery was the only vessel requiring ligature. Two sutures were inserted, and water dressing was applied. The forefinger was amputated so as to leave the base of the second phalanx intact. The hand and forearm were placed on a light anterior splint, and a bandage was applied over all.

On the 22nd, the day after the operation, the hand felt quite comfortable and there was little febrile disturbance. On the 23rd, fresh dressings were applied, the lint being arranged in strips like a many-tailed bandage so as to disturb the wound as little as possible, the patient going on very favourably. Nutritious diet was ordered. On the 28th, the parts were found to be healing kindly with no swelling or inflammation in the arm, and so little discharge that the wound was directed to be dressed only on alternate days. The forefinger has now almost healed. On June 2nd, twelve days after the accident, the patient was permitted to rise, and from this date until her discharge from hospital she continued to get on in every respect well. The splint was shifted by degrees a little higher up, as the parts gained solidity sufficient to permit them to dispense with its support, and also to leave the thumb and stump of the forefinger freedom to

During the cicatrization of the wound the hand if permitted would have been drawn towards the ulnar side, but this tendency was counteracted after a time by the careful management of the splint and dressings. Six weeks after admission, namely on the 3rd July, the child left the hospital in the following condition. The wound at the wrist had almost quite healed. There was some motion in the substitute for the joint. The stump of the forefinger was quite healed, but there was little power of apposing the thumb to it. The ball of the thumb was atrophied and the joints of both fingers were very stiff. The patient was enjoined to use the hand as much as possible, for the purpose of realizing free motion in the different joints, and exercising the residuary muscles.

In September, two months after, the report is that since leaving hospital the child, through fear of incurring pain, does not fully carry out the instructions given to her. Nevertheless, she has gained a considerable amount of power. She can move the wrist freely, pick up small objects and carry a light basket. No doubt exercise will impart additional facilities in respect of using those portions of the hand which have been preserved.

I have since taken care to see that my directions were complied with, and the result has been most satisfactory. The first figure in Plate I. represents the girl in the act of knitting, which she does with rapidity and ease. It, as well as the other figure on the plate, is copied from a photograph. The hand has gained greatly in strength. The ball of the thumb has begun to get firm again. The different joints are supple, the motion at the wrist is almost as free as if the joint were yet intact, and there is considerable power of apposing

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